The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The 24-hour oral intake is 600 ml greater than the total output.

The patient's temperature is 100.3" F 137.9" C).

The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating

The patient's calf is swollen, warm, and painful.

Answer and Explanation

The Correct Answer is D

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

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Correct Answer is C

Explanation

Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.

Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.

Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.

Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.

A. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain B. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL C. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL D. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Correct Answer is B

Explanation

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the first few days after surgery for cleft lip, which intervention should the nurse implement?

Correct Answer is C

Explanation

After a change-of-shift report, which client should the nurse assess first?

Correct Answer is B

Explanation

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency? SELECT ALL THAT APPLY

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

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A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for?

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